Plagues in World History

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Contents

Introduction 1
Chapter 1 Plague 19
Chapter 2 Smallpox 73
Chapter 3 Tuberculosis 89
Chapter 4 Cholera 101
Chapter 5 Influenza 111
Chapter 6 AIDS 135
Conclusion 179
Notes 185
Bibliography 215
Index 233
About the Author 244

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 y
Introduction

Why study disease? It’s not a very pleasant subject to contemplate. The pages of its
history are full of suffering and death. Its comings and goings often seem arbitrary
and simply inexplicable, the bane of most historians. There is no happy ending.
And yet . . . there is something about plagues that fascinates. For those with
morbid minds, the spectacle of mass death is mesmerizing in its capacity to inspire
fear, panic, viciousness, and cruelty. But for those of us who hold out some hope
for humanity, there is also to be found—even in a time of plague—kindness,
generosity, courage, and heroism. Truly, an epidemic tempers a society, subjecting
it to trials either to which it must succumb or over which it must triumph. There
is no middle ground with plague. It is the litmus test of civilizations.
Obviously, for our purposes, plagues and disease will be used interchangeably.
Even though “plague” does refer to a specific disease,1 which will be a main focus
of this book, the origins of the term can be traced back to the Latin word plaga,
meaning a “blow” or “wound.”2 While in the classical context of the Latin lan-
guage plague might be associated with a misfortune or disaster of some kind, it
was not necessarily associated with disease; this only seems to have emerged dur-
ing the late Roman Empire, when the Church issued a definitive Latin “Vulgate”
edition of the Old and New Testaments, largely through the labors of St. Jerome,
by 405 C.E. In this new context, plague naturally came to mean a “blow” from
on high, such as when the Hebrew God struck down every firstborn male in
Egypt, as recounted in the Book of Exodus. But this idea, if not the term, for
plague was a common inheritance from the ancients, all of whom viewed disease
as naturally emanating from the gods. Like the Hebrews, the Greeks could

1
2╇╇ y╇╇ Introduction

conceive of disease as a punishment or test for humans, with perhaps the most
famous example being Apollo using his silver bow to rain down plague upon the
Greeks, after Agamemnon had insulted his priest, Chryses, in the opening pages
of Homer’s epic poem The Iliad. But in older Egyptian and Mesopotamian cul-
tures, the reasons for the gods sending down disease could also be rather myste-
rious and unfathomable.
The history of disease, of course, is very old. It goes right back to the very begin-
nings of humanity, when men and women first became aware of the pain and
suffering caused by abnormal conditions, such as the invasion of their bodies by
other organisms. Ever since they evolved from apes, humans were infected by the
same diseases that afflicted their primate ancestors and that were caused by mi-
crobes that originated and adapted to their hosts millions of years ago. Some of
these “heirloom” infections include herpes, hepatitis, and yellow fever, all caused
by viruses, as well as malaria, caused by a plasmodium. Later, when humans be-
came hunters, other diseases passed to them from animals when they ate raw or
partially cooked meats. For instance, Paleolithic man may have suffered from a
variety of bacterial diseases, including anthrax, brucellosis, tularemia, and glanders,
as a result of the microbes being present in the wild game they hunted.3
However, the opportunities for disease causation and spread are thought to
have increased dramatically with the advent of settled agriculture at the dawn of
the Neolithic period in c. 8000 B.C.E. Maintaining close and regular contact
with domesticated animals, not to mention with other humans, as well as creating
stagnant reservoir pools such as irrigation ditches and accumulating large amounts
of human waste, perhaps within contaminating distance of drinking supplies,
opened a new chapter in the disease history of humankind by allowing illnesses
to become endemic, or perpetually present, in the artificial microbe pools thus
created. Chronic diseases that could thrive even in small populations and that
were associated with the new, man-made environments include tuberculosis,
schistosomiasis, and typhoid fever. However, some “density-dependent” diseases,
such as measles or smallpox, that may have originated in Neolithic man’s new-
found relationship with domesticated animals nonetheless had to wait until hu-
man populations became large enough to sustain them, which could not have
happened much before 3000 B.C.E. Other ills that are caused by dietary deficien-
cies also increased at this time, despite the fact that more and steadier supplies of
food were now available, since this was offset by a decline in the variety of foods
that had formerly been consumed under more nomadic circumstances.4
Eventually, trade, war, migrations, and other activities that brought distant hu-
man populations together were also to add to this disease environment, of which
illnesses like plague and influenza were to be the primary beneficiaries. Early hu-
mans also made efforts to counteract or compensate for disease-ridden conditions
 Introduction╇╇ y╇╇ 3

by designing sewer systems, imposing unclean food taboos, or setting up social

barriers between disparate populations or “castes,” such as were distinctive features
of ancient civilizations in India and Palestine (Hebrew culture). Yet, such efforts
may have had mixed success. For example, the impressive sewer systems uncovered
in the urban environments of Mohenjo-Daro and Harappa, part of the Indus River
valley civilization in India dating to around 2600 B.C.E., even boasts individual
household latrines connecting to the underground drains. It would seem obvious
that this was part of an effort to contain waste contamination and protect freshwa-
ter drinking supplies, but one should not discount the possibility that it was
equally motivated by a desire to efficiently collect waste for use as fertilizer, in
which case the likelihood of contracting disease would only increase.5
Toward the end of the Neolithic period, we begin to accumulate other evi-
dence of the impact of disease upon human societies aside from the archaeo-
logical. Our most valuable sources now become the written records that first
make their appearance around 3000 B.C.E. Perhaps the earliest descriptions of
and references to disease can be found in ancient Mesopotamian literature. The
epic poem Gilgamesh, written down around 2000 B.C.E. but recounting events
that apparently occurred several centuries earlier, tells of how the hero’s friend,
Enkidu, contracts a debilitating illness that confines him to his bed for twelve
days until he dies. The identity of the disease that kills Enkidu is never made
clear, for its symptoms are not described; we know only that it causes Enkidu
great pain and that he ascribes it to the curse of the gods in retribution for slay-
ing the Bull of Heaven. However, further details as to what this illness may have
entailed are supplied by the “Poem of the Righteous Sufferer,” part of the Meso-
potamian wisdom literature dating to the Babylonian period during the first half
of the third millennium B.C.E. Like Enkidu, the “Babylonian Job” lies prostrate
in his bed, although his condition is more fully described: He has become deaf,
blind, and dumb; a stiffness has taken over his limbs; and his flesh has become
emaciated and inflamed. All this is accompanied by a headache, intestinal dis-
tress, and discharge of phlegm; at its worst, the disease forces the patient to spend
“the night in my dung like an ox” and wallow “in my excrement like a sheep.” If
the disease has come from the gods, the sufferer remains mystified as to why,
since he has performed all of the usual rituals, libations, prayers, and other ob-
servances in honor of his deities. Like the later biblical Job, however, the sufferer
is eventually redeemed by the Babylonian god Marduk, who restores him to his
former health and happiness.
From the almost equally ancient Egyptian culture comes the first recorded
medical literature in history, the medical or surgical papyri, the oldest of which
perhaps dates to the time of Imhotep in the 2600s B.C.E., even though the
manuscript itself was not written down until about a thousand years later. In
4╇╇ y╇╇ Introduction

these medical papyri, Egyptian physicians describe both the medical conditions
they are trying to treat—which as often as not are trauma instead of disease re-
lated—and their remedies, which include both magical incantations and more
“rational” techniques such as surgery and herbal recipes. Interpretation of these
texts, however, is hampered by the still inexact knowledge of hieroglyphics and
by the fact that the ancient Egyptian mind-set was quite unlike our modern
outlook.6 In addition, Egyptian art, despite its often stylized representations,
sometimes depicts spinal or limb abnormalities in statuary and relief carvings of
its subjects, deformities that were possibly caused by disease. Finally, on occasion
we are fortunate enough to have the physical evidence of the diseased body itself,
preserved in mummified form with even the skin still intact, a unique contribu-
tion of ancient Egyptian culture. This has allowed scholars to detect diseases even
when they did not penetrate to the bone, such as the smallpox lesions evident on
the lower face, neck, and shoulders of the pharaoh, Ramses V, who died in c.
1145 B.C.E.7 In addition to smallpox, Egyptian mummies have also pointed to
the presence of tuberculosis, schistosomiasis, and poliomyelitis.
Before leaving the second millennium, we should not omit the oracle bones
dating from the Shang dynasty in China between c. 1500 and 1050 B.C.E.
These contain, for their time, some quite remarkable conceptions of disease,
centering around the chi, a logographic symbol depicting a man lying on a bed
pierced by the arrow of disease. This obviously anticipates biblical and classical
Greek references to “plague” in the sense of a blow sent down upon humans from
on high, but in ancient Chinese culture, the notion of any higher power being
responsible for disease seems to be absent, as the Chinese preferred to explain the
origins of their civilization in purely humanistic terms going back to mighty
ancestors. Instead, the disease agent is more rationally explained as due to a
worm or insect of some kind, as in the li and ku symbols, perhaps referring to
schistosomiasis. The ancient Chinese also identified diseases with fever or rash-
like symptoms, such as malaria or scabies, and made more amorphous references
to sensory, intestinal, and reproductive illnesses.8
In the last millennium before Christ, humankind entered a new era in writing
about disease. References to disease epidemics multiply in the Bible, but its use of
generalized terms such as “plague” make identification of specific illnesses diffi-
cult.9 Fully half of the references to plague in the Bible occur in the first five books
of the Old Testament, known collectively as the Torah or Pentateuch, which were
composed over the course of half a millennium from the tenth to the fifth centu-
ries B.C.E. In Leviticus and Deuteronomy, which contain approximately sixty
mentions of the term, plague is associated with a skin disease that may have been
leprosy.10 While the sixth plague that afflicted the Egyptians in Exodus 9:10 and
the plague that struck down the Philistines in 1 Samuel 4:6 are traditionally as-
 Introduction╇╇ y╇╇ 5

sociated with true plague due to references to “boils” and “tumors,” it remains
inconclusive whether the original Hebrew supports such an interpretation.11
Moreover, the Bible perpetuates older conceptions of disease causation,
namely, that the source of illnesses is to be attributed to a higher power. At
roughly the same time, however, alternative explanations of disease began to
emerge in other cultures in India, China, and Greece. Remarkably, all three
proposed similar systems that located diseases’ origins in humankind’s natural
environment and defined the disease condition within the body as resulting from
an imbalance of its core elements. This was undoubtedly the beginning of a truly
rational approach to disease and medicine, which used dietary and other health
regimens to prevent illness and natural compounds, bleeding, and other, human-
inspired techniques to cure it. But it is important to remember that these same
ancient societies by no means abandoned religious or supernatural methods of
healing, such as prayers and magical incantations, since desperate patients would
have been willing to try any remedy that might work, and the two realms of
religion and medicine were not seen as incompatible.12
Most influential for the West, of course, was the Greek medical tradition
founded by Hippocrates of Cos (c. 460–377 B.C.E.). Along with the body of
works attributed to him, known collectively as the “Hippocratic corpus,” Hip-
pocrates and his circle of physicians advocated the humoral theory as an explana-
tion of disease occurrences in the body, namely, that any given illness resulted
when the four humors of the body—blood, phlegm, yellow bile (cholera), and
black bile (melancholia)—were in a state of imbalance, a condition the Greeks
called dyscrasia, literally, “bad mixture.” But readers should know that very simi-
lar systems had also been proposed in ancient Indian and Chinese medicine. The
Ayurvedic tradition, compiled around the sixth century B.C.E. as one of India’s
sacred Veda texts, states that human health is connected to the three dosas, or
humors: these include Vayu, a dynamic, kinetic principle associated with air;
Pitta, a thermal, explosive force identified with the sun; and Kapha, a cohesive
principle that binds everything together. Balance of the dosas is to be maintained
not only by diet and personal habits but also by mental attitudes and even social
taboos that must be observed in accordance with the Hindu caste system.13
Likewise, ancient Chinese medicine, culminating in the Huangdi Nei Jing
(The Yellow Emperor’s Classic of Medicine), dating to the first century B.C.E.,
proposed a sixfold classification system of diagnosis that, in its crudest, most
simplified form, attempts to strike a balance between the two opposing yin-yang
qualities of the body and explained illnesses as resulting from an imbalance in
the body’s qi, a nearly untranslatable term that seems to encompass everything
that maintains life. Chinese medical tradition, going back to the Chou dynasty
(1050–256 B.C.E.), also relates the advent of diseases to the four seasons and to
6╇╇ y╇╇ Introduction

any abnormalities in their cycle (such as cool spring weather in the summer or
hot summer weather in the autumn). This is very similar to how works in the
Hippocratic corpus, such as On Airs, Waters, and Places, explain disease. Like the
Greeks, the Chinese also related the advent of disease to other factors including
changes in the air and other aspects of the environment, excessive emotional
states, and what the Greeks called bad regimen, such as overexertion, poor diet
and hygiene, immoral behaviors such as drunkenness and sexual indulgence, and
so on. But while the Greek miasmatic theory of bad air (the original malaria)
allowed for the concept of contagion, or the direct spread of disease from person
to person through the passing of the miasma, this never seems to have entered
the classical Chinese medical tradition. And while the Greeks related their hu-
mors to four basic elements of the universe, namely, air, water, earth, and fire,
the Chinese tradition lists five: wood, fire, earth, metal, and water.14 Altogether,
this ancient heritage identifies an impressive galaxy of diseases; judging from the
symptoms described, the ancients likely suffered from cholera, malaria, mumps,
measles, leprosy, erysipelas, dysentery, epilepsy, diphtheria, smallpox, tuberculo-
sis, typhoid fever, cancer, influenza, beriberi, rickets, pneumonia, cirrhosis,
asthma, arthritis . . . the list goes on and on.15
Nonetheless, the real history of disease could be said to have begun in 430–426
B.C.E., when a plague struck the city of Athens at the very start of the Pelopon-
nesian War with its rival, Sparta. For it was the Plague of Athens that inspired the
famous account of it by the Greek historian Thucydides as part of his History of the
Peloponnesian War. Many would regard Thucydides’ brief but compelling narrative
of the plague as the first example of historical writing about disease. This should
be attributed to not only the rational, “enlightened” approach that he takes to
disease (a path that was being concurrently blazed by the Hippocratics) but also
the comprehensive way in which he discusses the plague’s impact, which he sees as
affecting the entire body politic and not just the individual patient’s body.
Significantly, Thucydides states at the outset that he is eschewing all specula-
tion about the plague’s origin or causes, perhaps because he has no wish to bring
the gods into the discussion, as most other ancient authors would have been
tempted to do. This rigorously scientific approach, while paralleling that in con-
temporary Hippocratic medicine, was probably an entirely unrelated and inde-
pendent phenomenon.16 Above all, Thucydides’ preoccupation with disease
could be described as quintessentially historical: to describe it in such a way that
could prove useful to successive generations of his readers. Consequently, Thucy-
dides’ first order of business is to enumerate the characteristic symptoms of the
disease, by means of which it can be readily identified by future sufferers; it is a
task for which Thucydides was uniquely qualified, as he himself had contracted
the disease and survived to tell the tale. These symptoms include a burning fever,
 Introduction╇╇ y╇╇ 7

inflammation of the throat and tongue, small pustules or ulcers on the skin,
nauseating diarrhea and other discharges, and gangrene of the extremities,
which, if they killed the victim, did so in about a week. Yet, despite this painstak-
ing description, modern historians have endlessly debated exactly what kind of
disease afflicted Athenians during the plague. While it assuredly was not the
disease known as bubonic plague, since the characteristic symptom of the bubo
is not present in Thucydides’ account, consensus opinion seems to have co-
alesced around smallpox, although other candidates, including typhus, typhoid
fever, measles, and anthrax, also have been proposed.17
But what elevates Thucydides’ narrative to far above the ordinary is his ensu-
ing discussion of the social effects of the plague. In a profoundly perceptive
analysis, Thucydides notes how the plague overturned the conventions of his
society, whether these be in terms of funerary rites, religious observances, respect
for the laws and morals, or even the obligations of family members to care for
sick loved ones. It was Thucydides who first advanced the idea that people typi-
cally respond to the threat of mass death from disease with a “live for the mo-
ment” attitude as they await the imminent prospect of their own potential de-
mise. As he puts it in a justly famous passage,

Men now coolly ventured on what they had formerly done in a corner and not just
where they pleased, seeing the rapid transitions produced by persons in prosperity
suddenly dying and those who before had nothing succeeding to their property. So
they resolved to spend quickly and enjoy themselves, regarding their lives and
riches as alike things of a day. Perseverance in what men called honor was popular
with none, it was so uncertain whether they would be spared to attain the object;
but it was settled that present enjoyment, and all that contributed to it, was both
honorable and useful. Fear of gods or law of man there was none to restrain them.
As for the first, they judged it to be just the same whether they worshipped them
or not, as they saw all alike perishing; and for the last, no one expected to live to
be brought to trial for his offences, but each felt that a far severer sentence had
been already passed upon them all and hung ever over their heads, and before this
fell it was only reasonable to enjoy life a little.18

However, it should be noted here that other Greek sources also record a more
conservative reaction to the plague, one that reaffirmed the role of the gods in
terms of being able to both cause and cure disease, as evidenced by the rising
popularity of the healing cult of Asclepius, son of Apollo, in the decades follow-
ing the Plague of Athens. Not surprisingly, this reactionary attitude receives al-
most no mention from Thucydides.19
Perhaps the greatest contribution of Thucydides to the history of disease is his
implied notion that a disease not only infects individuals but also makes all of
8╇╇ y╇╇ Introduction

society, an entire community, its victim. For a disease, he makes clear, not only
affects people’s health and well-being but also can determine the fate of large-
scale events and situations, even if only in an indirect way. Although he doesn’t
say so explicitly, Thucydides does seem to suggest that the Plague of Athens al-
tered the whole course of the Peloponnesian War, as indicated by his insertion of
the narrative of the disease directly following his account of the funeral oration
of Pericles that laid out Athenians’ justification for fighting the war.20 Whether
the plague had longer-term effects, however, that resulted in the decline and
ultimate fall of the Athenian empire by the end of the war in 404 is a subject that
continues to be debated by historians.21
Somewhat later in his account, Thucydides does say that nothing did as much
harm to the Athenian war effort as the plague: in purely military terms, the dis-
ease wiped out 4,400 hoplites and 300 cavalrymen, who most likely represented
roughly a third of available forces. Although Thucydides asserts that the plague’s
decimations among the general population are undiscoverable, modern calcula-
tions—assuming a death rate commensurate with that among the army—yield
figures in the tens of thousands.22 With its manpower thus sharply curtailed,
Athens was severely hampered in terms of the scope of both land and sea opera-
tions; it was not until more than a decade later, in 415, that the Athenians felt
capable of launching the ill-fated Sicilian expedition.
But beyond mere numbers, the plague may also have affected how the Athe-
nians fought the entire rest of the war, even though the disease occurred so early
in the conflict.23 Thucydides seems to credit the plague with inculcating a moral
failing, or “lawlessness,” in the Athenian character, which was to show up later
in the war in the form of ruthless and ultimately self-destructive policies, such as
its brutal conduct toward the neutral island of Melos in 416, which in Thucy-
dides’ famous “dialogue” foreshadows inhumane treatment of Athens’ own sol-
diers when taken prisoner at Syracuse. Yet, it’s hard to know if this is really the
case, since Athens already revealed a ruthless streak early in its empire when it
refused to allow the island of Naxos to secede from the Delian League in 467.
Thucydides also notes that the plague was worldwide in its scope; for example,
he states that it started in Ethiopia in sub-Saharan Africa and progressed from
there northward and westward to Egypt and Libya and eastward to the Persian
Empire. Therefore, in so many ways, Thucydides’ history of the Plague of Athens
provides a model for all other histories of disease that were to follow.24
If we now shift our focus to modern historical writing about disease, it
quickly becomes apparent that we have expanded considerably upon Thucy-
dides’ revolutionary rationality. In terms of the scope, importance, complexity,
diversity, and a host of other factors to consider about disease, we have gone
well beyond Thucydides’ original speculations, even when following the basic
 Introduction╇╇ y╇╇ 9

lines of his thought. In the first place, whole books have now been devoted to
the role that disease played in history, instead of the subject occupying but a
minor part in the broader historical narrative. The traditional approach (some-
times also called the “positivist” or “biological” school) of modern historical
writing is to follow most ancient authors in treating disease as a discretely de-
fined, exogenous, or foreign variable (now a microorganism rather than an ar-
row from on high) that suddenly invades a population and wreaks havoc upon
it. Taking their cue from Thucydides, who emphasizes how the death from
plague of one man, Pericles, altered Athens’ subsequent fortunes in the Pelo-
ponnesian War, these writers stress the almost whimsical role that disease has
played in dramatically changing the lives and course of historical personalities
and events.25 Aligned with this approach are those historians who chronicle
humans’ heroic struggle to medically “conquer” the biological enemy repre-
sented by disease, a war that mankind, until recently, seemed to be winning as
history progressed.26
Then along came William McNeill’s Plagues and Peoples in 1976, which some
would consider as bringing about a seismic shift in historical studies of disease.
McNeill himself claimed to be writing a new chapter in disease history, ascribing
to epidemics an importance not previously found in historical surveys. Even
though McNeill did pay homage to “antiquarians,” such as Hans Zinsser, for
pointing out isolated disease incidents such as the Black Death that briefly com-
manded the historical stage, such acknowledgments, he claimed, were rare and
made historians uncomfortable because they did not fit in with their orderly
views of the past.27
By contrast, McNeill, a world historian who emphasizes cultural fusions
among different civilizations that eventually led to Western dominance of the
globe,28 adapts this approach to disease in order to accord it a central place in
world events. This is especially the case when new technologies or cultural devel-
opments enable a disease to become “pandemic,” that is, to be communicated to
distant lands far from its epicenter and thus have a dramatic impact on “virgin
soil” populations with no prior exposure or immunity to it. McNeill’s classic ex-
ample of this, and the one that actually inspired his book, is the introduction of
smallpox to the Americas in the early sixteenth century and the resulting horrific
mortalities among Native American populations there; according to McNeill,
smallpox by itself is sufficient to explain how conquistadors such as Hernán Cor-
tés and Francisco Pizarro overcame overwhelming odds to swiftly conquer the
once-mighty Aztec and Inca empires in Mexico and Peru.29 In addition to such
“transoceanic exchanges,” McNeill devotes another chapter to the role played by
the Mongol Empire during the late Middle Ages in the dissemination of the Black
Death, both east and west. His concluding chapter is perhaps his most conven-
10╇╇ y╇╇ Introduction

tional, tracing the now familiar success stories of modern medical science in
conquering disease from the eighteenth to the twentieth centuries.
So far, nothing that McNeill has to say is exactly new; as a matter of fact, most
of what is mentioned above could be fairly said to have been anticipated by the
ancient historian Thucydides. For it was Thucydides who first pointed to the
world scope of disease, to its devastating impact upon a population unprepared
for it, and even to the central role disease could play in history. But I believe that
McNeill has made two contributions to the history of disease that are important
and unique.
In the first place, McNeill introduces the idea that disease can be a relative
construct, not just a discrete biological entity. Although McNeill uses “macropar-
asitism” to refer to one class of human beings living off the productive capacity
of another class, one can also conceive of it in environmental terms, in which
humans through their variegated behaviors alter their disease environment,
which in turn adapts to their modifications, and so on in an unending war of
mutual attrition; in many respects, this is comparable to how microparasites have
adapted to their human and animal hosts, selectively evolving to neither kill
them outright nor in turn be eliminated completely. In this way then, human
beings can, in effect, create their own sense of just what is a disease. McNeill fully
realizes that this can change “the very concept of disease,” making it entirely
dependent on social and historical circumstances. As an example, nearsighted-
ness and a “dull sense of smell” may be considered perfectly normal in today’s
society, but they would have been crippling debilities—indeed a disease—among
Paleolithic hunters struggling to survive. However, McNeill rejects a completely
relativist approach to disease, preferring to hold onto “a firm and universal nu-
cleus to the concept of disease,” one in which “bodily disorder” mainly arises
from “parasitic organisms.”30
Despite McNeill’s reservations, the relativist, or “social constructionist,” ap-
proach, which increasingly viewed disease as an endogenous phenomenon arising
solely out of factors intrinsic to the society or culture in which it occurs, became
more popular among historians, particularly during the 1980s; for it was at that
time that the emerging AIDS pandemic seemed to be a perfect illustration of how
a disease can be a function of socially risky behaviors.31 Indeed, one historian in
this school goes so far as to suggest, perhaps facetiously, that one day harmless skin
freckles may be deemed unsightly enough to be classified as a disease, complete
with a “National Institute of Freckle Research” devoted to eradicating them.32
However, if one goes to extremes with such an argument, one wonders what
historical statements, if any, can be made about disease, if the very definition of
the term is subject to such speculation. It seems that McNeill was right to insist
upon a commonsense foundation from which to start a discussion.
 Introduction╇╇ y╇╇ 11

McNeill’s other contribution comes at the end of his book, where he specu-
lates about the future of disease history. Despite the fact that Plagues and Peoples
came out at the very same time that the World Health Organization was success-
fully eradicating smallpox, and in stark contrast to traditional views of medical
historians that foresaw an “end to epidemics,” McNeill concludes that infectious
disease will remain an inseparable part of the history of humanity, indeed, for as
long as humanity itself continues to exist. Ironically, he sees the very success of
medical treatments of disease as only contributing to its perpetuation. A good
example is the rash of polio infections that broke out among even the higher
classes of American society in the mid-twentieth century, a circumstance attrib-
utable, McNeill insists, to the higher standards of hygiene that wiped out minor
infections among children, which earlier had conferred some immunity to more
serious, full-blown infections.33 In a new preface written in 1997 to take account
of the current AIDS pandemic, McNeill maintained his pessimistic view of hu-
mankind’s ability to “conquer” disease, citing the worldwide AIDS crisis as just
one more example of how the global transmission of disease was only accelerat-
ing the biological evolution and adaptation of microorganisms to their hosts.34
The efforts of humanity—the “macroparasite”—to wipe out disease were upset-
ting the natural balance and, as recent disease history made clear, was only mak-
ing things worse, not better. This gloomy perspective has been taken up by a host
of far less restrained authors who peddle an alarmist, even apocalyptic, scenario
where disease in the end conquers humankind, not the other way around.35
On a very basic level, one can both agree and disagree with McNeill’s thesis
that disease has played a central role in human history. It seems an intuitive fact
that most people who die a “natural death” do so as the result of some disease or
other, rather than being blessed with the good fortune of dying of extreme old
age, when the cells of the body simply cease to divide and function. In this re-
gard, disease is almost as ubiquitous as death in terms of its presence and impor-
tance in our everyday lives. Yet, one could also argue that the very fact that
populations around the globe are increasing in number, and have done so at
varying rates of propagation throughout history, prove that human fortunes are
rarely dictated or limited by disease and its consequent mortality. Instead, one
might counter that it is restrictions on reproductive capacity (aside from disease)
that have played the greater role in the course of human development, such as
the availability of food and other material resources that, from a Malthusian
point of view, are forever locked with population in a struggle to achieve equi-
librium or balance.36 In a way, McNeill has sidestepped this whole conundrum
by only focusing on large-scale, global pandemics of disease, whose mortalities
posed extraordinary challenges to civilizations. His example, by necessity, will be
followed in this book.